Gregory R. Waryasz, MD; Todd Borenstein, MD; Robert Tambone, MS; and arm pain: Joseph A. Gil, MD; Manuel DaSilva, MD Department of Orthopaedic A pictorial guide to injections Surgery, Brown University/- Rhode Island Hospital, Provi- dence (Drs. Waryasz, This article, with illustrative figures, will help you get Borenstein, Gil, and DaSilva); New York Medi- to the cause of your patient’s pain and guide your cal College, Valhalla (Dr. Tambone) administration of injections.

gregory.waryasz.md@ gmail.com

The authors reported no potential conflict of interest rimary care physicians are frequently the first to evaluate relevant to this article. PRACTICE hand, wrist, and forearm pain in patients, making knowl- RECOMMENDATIONS edge of the symptoms, causes, and treatment of common ❯ Diagnose common upper P diagnoses in the upper extremities imperative. Primary symp- extremity conditions based on toms usually include pain and/or swelling. While most anatomic relationships. B disorders originating in the hand and wrist are idiopathic in ❯ Refer patients who do not nature, some patients occasionally report having recently per- respond to splinting, corti- formed unusual manual activity or having experienced trauma costeroid injections, or other to the area days or weeks prior. A significant portion of patients conservative therapies to a are injured as a result of chronic repetitive activities at work.1 surgeon for evaluation. B Most diagnoses can be made by pairing your knowledge

Strength of recommendation (SOR) of hand and forearm anatomy with an understanding of which A Good-quality patient-oriented tender points are indicative of which common conditions. evidence (Care, of course, must be taken to ensure that there is no un- B Inconsistent or limited-quality patient-oriented evidence derlying infection.) Common conditions can often be treated  C Consensus, usual practice, nonsurgically with conservative treatments such as physical opinion, disease-oriented therapy, bracing/splinting, nonsteroidal anti-inflammatory evidence, case series drugs (NSAIDs), and injections of (eg, beta- methasone, hydrocortisone, , and triam- cinolone) (TABLE 12-4) with or without the use of ultrasound. The benefits of corticosteroid injections for these conditions are well studied and documented in the literature, although physicians should always warn patients of the possible adverse effects prior to injection3,5 (TABLE 24). To help you refine your skills, we review some of the more common hand and forearm conditions you are likely to en- counter in the office and provide photos that reveal underly- ing anatomy so that you can administer injections without, in many cases, the need for ultrasound.

Trigger finger/: New pathophysiologic findings? most commonly occurs in the dominant hand. It is also more common in women, patients in their 50s, and

492 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 Most diagnoses can be made by pairing your knowledge of hand and forearm anatomy with an understanding of which tender points are indicative of which common conditions.

in individuals with .6 Trigger finger/- grecan, and biglycan are up-regulated, while thumb is caused by and con- metalloproteinase inhibitor 3 (TIMP-3) and striction of the flexor , which matrix metallopeptidase3 (MMP-3) are down- carries the flexor through the palm regulated, a situation also described in Achil- and into the fingers and thumb. This, in turn, les tendinosis.7 This similarity in conditions causes irritation of the tendons, sometimes provides new insight into the pathophysiology via the formation of tendinous nodules, of the condition and may help provide future which may impinge upon the sheath’s “pulley treatments. system.” ❚ When the “pulley” is compromised. Making the Dx: The retinacular sheath is composed of 5 an- Look for swelling, check for carpal tunnel nular ligaments, or pulleys, that hold the During the examination, first look at both tendons of the fingers close to the bone and for swelling, , or injury, allow the fingers to flex properly. The A1 pul- and note the presence of any joint contrac- ley, at the level of the metacarpal head, is the tures. Next, examine all of the digits in flex- first part of the sheath and is subject to the ion and extension while noting which ones highest force; high forces may subsequently are triggering, as the problem can occur in lead to the finger becoming locked in a flexed, multiple digits on one hand. Then palpate the or trigger, position.6 Patients may experience palms over the patient’s metacarpal heads, pain in the distal palm at the level of the feeling for tender nodules. A1 pulley and clicking of the finger.6 Finally, examine the patient for carpal IMAGE: © JOE GORMAN ❚ Additionally . . . recent studies show tunnel syndrome (CTS). A positive Tinel’s discrete histologic changes in trigger finger sign (shooting pain into the hand when the tendons, similar to findings with Achilles median nerve in the wrist is percussed), a tendinosis and .7 In trigger fin- positive Phalen maneuver (numbness or ger tendons, collagen type 1A1 and 3A1, ag- pain, usually within one minute of full wrist

JFPONLINE.COM VOL 66, NO 8 | AUGUST 2017 | THE JOURNAL OF FAMILY PRACTICE 493 TABLE 1 Common corticosteroids and injection doses2-4

Medication Dose Betamethasone sodium phosphate/betamethasone acetate 1.5-3 mg for tendon sheath/small joint

Hydrocortisone 25-100 mg for carpal tunnel Methylprednisolone acetate 20-80 mg for tendon sheath/small joint Triamcinolone acetonide 10 mg for tendon sheath/small joint

flexion), or thenar muscle wasting are highly including nerve damage, are exceedingly indicative of CTS (compression of the me- rare, but injury can occur, given the proximity dian nerve at the transverse carpal liga- of the digital nerves to the A1 pulley. ment in the carpal tunnel). It is important ❚ Patient is a child? Refer children with to check for CTS when examining a patient trigger finger or thumb to a hand surgeon for for trigger finger because the 2 conditions evaluation and management because the in- frequently co-occur.6 (For more on CTS, see dications for nonoperative treatment in the page 496.) pediatric population are unclear.9

Treatment: Consider corticosteroids first Carpometacarpal arthritis: First-line treatment for patients with trigger Common, with many causes finger or thumb is a corticosteroid injection Osteoarthritis of the first carpometacarpal into the subcutaneous tissue around the ten- (CMC) joint is the most common site of ar- don sheath (FIGURES 1 and 2). (For this indica- thritis in the hand/wrist region, affecting up tion and for the others discussed throughout to 11% of men and 33% of women in their 50s the article, there isn’t tremendous evidence and 60s.10 Because the CMC joint lacks a bony for one particular type of corticosteroid over restraint, it relies on a number of ligaments for another; see TABLE 12-4 for choices.) Up to 57% stability—the strongest and most important of cases resolve with one injection, and 86% of which is the palmar oblique “beak” liga- resolve with 2,8 but keep in mind that it may ment.11 A major cause of degenerative arthritis take up to 2 weeks to achieve the full clinical of this joint is attenuation and laxity of these benefit. ligaments, leading to abnormal and increased Patients with multiple trigger fingers stress loads, which, in turn, can lead to loss of can be treated with oral corticosteroids (eg, a methylprednisolone dose pack). Peters- Veluthamaningal et al performed a system- TABLE 2 atic review in 2009 and found 2 randomized controlled trials involving 63 patients (34 re- Possible adverse effects ceived injections of a corticosteroid [either of steroid injections methylprednisolone or betamethasone] and Anaphylaxis lidocaine and 29 received lidocaine only).2 The corticosteroid/lidocaine combination Depigmentation of the skin was more effective at 4 weeks (relative risk Elevated blood glucose levels [RR]=3.15; 95% confidence interval [CI], Infection 1.34 to 7.40).2 Nerve injury If 2 corticosteroid injections 6 weeks apart fail to provide benefit, or the finger is Pain at injection site irreversibly locked in flexion, surgical release Subcutaneous fatty atrophy/necrosis of the pulley is required and is performed Tendon/fascial ruptures

through a palmar incision at the level of the Reprinted with permission from: Waryasz GR et al. R I Med A1 pulley. Complications from this surgery, J. 2017.4

494 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 HAND AND ARM PAIN

FIGURES 1 AND 2 Trigger finger/thumb injection* ALL FIGURE PHOTOS COURTESY OF: MANUEL DASILVA, MD

1. Clean the area with alcohol, chorhexidine, or iodine. 2. Use ethyl chloride spray prior to injection to provide temporary injection site pain relief. 3. Palpate the metacarpal head volarly. The A1 pulley is securing the flexor tendons at this level. 4. Inject the area proximal to the metacarpal head with a mixture of lidocaine/steroid (TABLE 12-4). 5. Feel the tendon sheath fill with the liquid mixture with your non-injection fingers. The patient typically reports immediate improvement in the clicking/triggering and/or pain that prompted the visit. 6. Palpate the A1 pulley as you flex and extend the metacarpophalangeal joint to see if the clicking/triggering and/or pain has improved. *The clinician performing the injection should wear sterile gloves; these photos were taken without gloves to better demonstrate hand position.

cartilage and bony impingement. While the It's important to focus on the dorsoradial exact mechanism of this process is not fully aspect of the thumb during the physical exam understood,10,12 acute or chronic trauma, ad- and to rule out other causes of pain, such as vanced age, hormonal factors, and genetic fac- de Quervain’s , flexor carpi radia- tors seem to play a role.11 lis tendinitis, CTS, and trigger thumb.11 Typical Many believe there is a relationship findings include pain with palpation directly between a patient's occupation and the de- over the dorsoradial aspect of the CMC joint velopment of CMC arthritis, but studies are and pain with axial loading and upon cir- inconclusive.13 At risk are secretarial work- cumduction during a Grind test of the CMC ers, tailors, domestic helpers/cleaners, and joint. (The Grind test is performed by moving individuals whose jobs involve repetitive the metacarpal bone of the thumb in a circle thumb use and/or insufficient rest of the joint and loading it with gentle axial forces. People throughout the day. with thumb joint arthritis generally experience sudden sharp pain at the CMC joint.) Making the Dx: Radiographic findings can be useful as Perform the Grind test a diagnostic adjunct, with staging of the dis- A detailed patient history (which is usu- ease, and in determining who can benefit ally void of trauma to the hand) and physi- from conservative management.11 cal examination are the keys to making the diagnosis of CMC arthritis. A history of pain Treatment: at the base of the thumb during pinching Start with NSAIDs and splinting and gripping tasks is often elucidated. Clas- Depending on the degree of arthritis, man- sically, patients describe pain upon turning agement may include both conservative and keys, opening jars, and gripping doorknobs.11 surgical options.10 Patient education describ-

JFPONLINE.COM VOL 66, NO 8 | AUGUST 2017 | THE JOURNAL OF FAMILY PRACTICE 495 FIGURE 3 patients with early-stage disease and may be Basal joint or thumb carpometacarpal joint used for either short-term flares or long-term treatment.11 injection* ❚ Cortisone injections. For those patients who do not respond to activity modification, NSAIDs, and/or splinting, consider cortisone injections (FIGURE 3). Intra-articular corti- sone injections can decrease inflammation and provide good pain relief, especially in patients with early-stage disease. The effec- tiveness of cortisone injections in patients with more advanced disease is not clear; no benefit has been shown in studies to date.16 Equally unclear is the long-term benefit of injections.11 Patients who do not respond to conservative treatments will often require surgical care. 1. Clean the area with alcohol, chorhexidine, or iodine. 2. Use ethyl chloride spray prior to injection to provide temporary injection site pain relief. : 3. Palpate the metacarpal base. Moving slower to surgery 4. Perform a Grind test (see page 495) to help confirm the location of the CMC joint. Traction to the joint can be helpful to increase the joint space. CTS is one of the most common conditions of 5. Inject the thumb CMC joint with a mixture of lidocaine/steroid (TABLE 12-4). The the upper extremities. Researchers estimate patient typically reports immediate improvement in the pain that prompted the that 491 women per 100,000 person-years and visit. 258 men per 100,000 person-years will de- *The clinician performing the injection should wear sterile gloves; this photo was taken without gloves to better demonstrate hand position. velop CTS, with 109 per 100,000 person-years receiving carpal tunnel release surgery.17 Risk factors for the development of CTS include ing activity modification is useful during all diabetes, hypothyroidism, rheumatoid arthri- stages of CMC arthritis. Research has shown tis, pregnancy, obesity, family history, trauma, that avoiding inciting activities, such as key and occupations that involve repetitive tasks turning, pinching, and grasping, helps to al- or long hours working at a computer.18 leviate symptoms.14 Patients may also obtain CTS is caused by compression of the relief from NSAIDs, especially when they median nerve as it passes through the carpal are used in conjunction with activity modi- tunnel.19 The elevated pressure in the carpal fication and splinting. NSAIDs, however, tunnel restricts epineural blood flow and do not halt or reverse the disease process; supply, causing the pain felt with CTS.20 Even they only reduce inflammation, , after surgical decompression, recurrent or and pain.11 persistent CTS can be a problem.21 ❚ Splinting. Studies have shown splint- ing of the thumb CMC joint to provide pain Making the Dx: Perform relief and to potentially slow disease progres- the Phalen maneuver, Durkan’s test sion.15 Because splints decrease motion and Patients typically present with complaints of increase joint stability, they are especially weakness, pain, and/or numbness in at least useful for patients with joint hypermobil- 2 of 4 radial digits (thumb, index, middle, ity. The long opponens thumb spica splint is ring).19,22 The most common time of day for commonly used; it immobilizes the wrist and patients to have symptoms is at night.21 CMC, while leaving the thumb interphalan- ❚ The diagnostic tools. Tinel’s sign is a geal joint free. Short thumb spica and neo- useful diagnostic tool when you suspect car- prene splints are also commercially available, pal tunnel syndrome. Tinel’s sign is positive if and studies have shown that they provide percussion over the median nerve at the car- good results.15 Splinting is most beneficial in pal tunnel elicits pain or paresthesia.18

496 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 HAND AND ARM PAIN

FIGURES 4 & 5 Carpal tunnel injection*

1. Clean the area with alcohol, chorhexidine, or iodine. 2. Use ethyl chloride spray prior to injection to provide temporary injection site pain relief. 3. Palpate the transverse carpal ligament at the distal wrist. 4. Inject the area proximal to the transverse carpal ligament with a mixture of lidocaine/steroid (TABLE 12-4) to infiltrate the carpal tunnel. The patient typically reports immediate numbness in the distribution of the median nerve or improvement in pain. *The clinician performing the injection should wear sterile gloves; these photos were taken without gloves to better demonstrate hand position.

When employing the Phalen maneu- The 5.07 monofilament test is performed ver, be certain to have the patient flex his/her with the clinician applying the monofilament wrist to 90 degrees and to document the num- to different dermatomal or sensory distri- ber of seconds it takes for numbness to present butions while the patient has his/her eyes in the fingers. Pain or paresthesia should oc- closed. The 2-point discrimination test is per- cur in <60 seconds for the test to be positive.18 formed with a caliper device that measures Median nerve compression over the car- the distance at which the patient can feel pal tunnel, also known as Durkan’s test, may 2 separate stimuli. Often electromyography also elicit symptoms. With Durkan’s test, you or nerve conduction studies are necessary.18 apply direct pressure over the transverse car- pal ligament. If pain or paresthesia occurs in Treatment: <30 seconds, the test is positive.18 Often clini- Pursue nonoperative approaches cians will combine the Phalen maneuver and A survey of the membership of the American Durkan’s test to increase sensitivity and spec- Society for Surgery of the Hand revealed that ificity.18 Nerve conduction studies are often surgeons are utilizing nonoperative treat- performed to confirm the clinical diagnosis. ments for a longer duration of time and are ❚ Is more than one condition at play? employing narrowed surgical indications.24 It is important to determine whether cervical Thus, clinicians are more likely to try splints spine disease and/or peripheral neuropathy and steroid injections before proceeding to is contributing to the patient’s symptoms, operative release.24 along with CTS; patients may have more than ❚ Nonsurgical management. In our prac- one condition contributing to their pain. We tice, we commonly recommend corticosteroid routinely check cervical spine motion, ten- injections (TABLE 12-4) into the carpal tunnel derness, and nerve compression as part of (FIGURES 4 and 5) to patients who are poor the exam on a patient with suspected CTS. candidates for surgery (ie, those who have In the office, a monofilament test or 2-point too many medical comorbidities or wound discrimination test can help make the clinical healing concerns). This is one indication for diagnosis by uncovering decreased sensation which you may want to consider ultrasound- in the thumb, index, and/or middle fingers.23 guided injections because the improved accu-

JFPONLINE.COM VOL 66, NO 8 | AUGUST 2017 | THE JOURNAL OF FAMILY PRACTICE 497 racy may provide symptom relief faster than tenosynovitis) involves painful inflamma- “blind” or palpation-guided injections.25 tion of the 2 tendons in the first dorsal com- A recent randomized controlled trial partment of the wrist—the abductor pollicis from Sweden showed that injections of meth- longus (APL) and the extensor pollicis brevis ylprednisolone relieved symptoms in pa- (EPB). The tendons comprise the radial bor- tients with mild to moderate CTS at 10 weeks der of the anatomic snuffbox. and reduced the rate of surgery one year after The APL abducts and extends the thumb treatment; however, 3 out of 4 patients still at the CMC joint, while the EPB extends went on to have surgery within a year.22 Pa- the thumb proximal phalanx at the meta- tients in the study had failed a 2-month trial carpophalangeal joint. These tendons are of splinting and were given either 80 mg or contained in a synovial sheath that is sub- 40 mg of methylprednisolone or saline. There ject to inflammation and constriction and was no statistical difference between the subsequent wear and damage.29 In addition, doses of methylprednisolone in preventing the extensor retinaculum in patients with surgery at one year. Compared to placebo, de Quervain’s disease demonstrates in- the 80-mg methylprednisolone group was creased vascularity and deposition of dense less likely to have surgery with an odds ratio fibrous tissue resulting in thickening of the of 0.24 (P=.042).22 tendon up to 5 times its normal width.30 There is evidence that oral steroids, in- As a result, degeneration and thickening Recent jected steroids, ultrasound, electromagnetic of the tendon sheath, as well as radial-sided studies show field therapy, nocturnal splinting, and use wrist pain elicited at the first dorsal compart- discrete of ergonomic keyboards are effective non- ment, are common pathophysiologic and histologic operative modalities in the short term, but clinical findings.31 Pain is often accompanied changes evidence is sparse for mid- or long-term by the build-up of protuberances and nodu- in trigger finger use.19 In addition, at least one randomized lations of the tendon sheath. tendons, similar trial found traditional cupping therapy ap- De Quervain’s disease commonly oc- to findings plied around the shoulder alleviated carpal curs during and after pregnancy.32 Other risk with Achilles tunnel symptoms in the short-term.26 Other factors include racquet sports, golfing, wrist tendinosis and nonoperative therapies include rest, NSAIDs, trauma, and other activities involving repeti- tendinopathy. extracorporeal shock wave therapy, and tive hand and wrist motions.33 Often, however, activity modification.19,27 de Quervain’s is idiopathic. ❚ Surgical outcomes by either endo- scopic, mini-open, or open surgical tech- Making the Dx: niques are typically good.20,21 Surgical release Perform a Finkelstein's test involves cutting the transverse carpal ligament The major finding in patients with de Quer- over the carpal tunnel to decompress the me- vain’s tenosynovitis is a positive Finkelstein's dian nerve.24 You should inform patients of the test. To perform Finkelstein's test (FIGURE 6), risks and inconveniences associated with sur- ask the patient to oppose the thumb into the gery, including the cost, absence from work, palm and flex the fingers of the same hand infection, and chronic pain. Patients who have over the thumb. Holding the patient’s fin- recurrent or persistent symptoms after surgery gers around the thumb, ulnarly deviate the may have had an incompletely released trans- wrist. Finkelstein's test puts strain on the APL verse carpal ligament or there may be no iden- and EPB, causing pain along the radial bor- tifiable cause.21 Overall, surgical treatment, der of the wrist and forearm in patients with combined with physical therapy, seems to be de Quervain’s tenosynovitis. Since the maneu- more effective than splinting or NSAIDs for ver can be uncomfortable, complete the exam mid- and long-term treatment of CTS.28 on the unaffected side for comparison. Stenosis of the tendon sheath may lead to crepitus over the first dorsal wrist com- De Quervain’s tenosynovitis: partment. This should be distinguished from Common during pregnancy intersection syndrome (tenosynovitis at the De Quervain’s tenosynovitis (radial styloid intersection of the first and second extensor

498 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 HAND AND ARM PAIN

compartments), which can also present with FIGURE 6 forearm and wrist crepitus. Patients usually Finkelstein’s test have swelling of the wrist with marked dis- comfort upon palpation of the radial ten- dons. An x-ray can be useful to evaluate for CMC or radiocarpal arthritis, which may be an underlying cause.

Treatment: Select an approach based on symptom severity In a retrospective analysis, Lane et al con- cluded that classification of patients with de Quervain’s disease based on pretreatment symptoms may assist physicians in selecting the most efficacious treatment and in provid- ing prognostic information to their patients (TABLE 334). Patients with mild to moderate (Types 1 and 2) de Quervain’s may benefit from immobilization in a thumb spica splint, rest, NSAIDs, and physical or occupational Check for carpal therapy. If work conditions played a role in tunnel syndrome causing the symptoms, they need to be ad- when examining dressed to improve outcomes. Types 2 and 3 a patient with can be initially treated with a corticosteroid in- Instruct the patient to perform a hook grip. The hook trigger finger; jection, but may eventually require surgery.33 grip means the index, middle, ring, and small fingers the 2 conditions ❚ are flexed over a flexed thumb. Sharply deviate the Treatment with NSAIDs or corticoste- wrist ulnarly. Pain along the first dorsal compartment is often co-occur. roid injections (see TABLE 12-4 for choices) in a positive test. the first compartment of the extensor reti- naculum (FIGURE 7) is usually adequate to provide relief. Peters-Veluthamaningal et al ional and college athletes may be prone to re- performed a systematic review in 2009 and calcitrant de Quervain’s tenosynovitis. A 2010 found only one controlled trial of 18 partici- study by Pagonis et al showed that recurrent pants (all pregnant or lactating women) who symptomatic episodes commonly occur in ath- were either injected with corticosteroids or letes who engage in high-resistance, intense given a thumb spica splint.35 All 9 patients in athletic training. In these severe cases, a 4-point the injection group had complete pain relief, injection technique offers better distribution whereas no one in the splint group had com- of corticosteroid solution to the first extensor plete resolution of symptoms.35 Typical ana- compartment than other methods.37 Consider tomic placement of corticosteroid injections referring severe cases to a hand surgeon. is shown in FIGURE 7. Surgical release of the first dorsal com- More complicated injection methods partmental sheath around the tendons serves have been described, but injecting the first as a final option for patients who fail conser- dorsal compartment is usually satisfactory. vative treatment. Care should be taken to re- Patients will feel the tendon sheath fill- lease both tendons completely, as there may ing with the injection material. The 2-point be at least 2 tendon slips of the APL or there technique, implemented by Sawaizumi et al, may be a distinct EPB sheath dorsally.38 which involves injecting corticosteroid into 2 points over the EPB and APL tendon in the area of maximum pain and thick- “”— you don’t ening, is more effective than the 1-point in- have to play tennis to have it jection technique.36 Lateral epicondylitis (tennis elbow) is a pain- ❚ Severe, recalcitrant cases. Profess- ful condition involving microtears within the

JFPONLINE.COM VOL 66, NO 8 | AUGUST 2017 | THE JOURNAL OF FAMILY PRACTICE 499 FIGURE 7 players, males are more often affected than Technique for de Quervain injection* females, whereas in the general population, incidence is approximately equal in men and women.41 Lateral epicondylitis occurs between 4 and 7 times more frequently than medial-sided elbow pain.42

Making the Dx: Look for localized pain, normal ROM The diagnosis of lateral epicondylitis is based upon a history of pain over the lateral epicon- dyle and findings on physical examination, including local tenderness directly over the lateral epicondyle,43 pain aggravated by re- sisted wrist extension and radial deviation, pain with resisted middle finger extension, and decreased grip strength or pain aggra- 1. Clean the area with alcohol, chorhexidine, or iodine. vated by strong gripping. These findings typi- 2. Use ethyl chloride spray prior to injection to provide temporary injection site pain relief. cally occur in the presence of normal elbow 3. Palpate the first dorsal compartment; typically there is a distinct tender location range of motion. over the radial aspect of the distal radius. 4. Infiltrate the area with a mixture of lidocaine/steroid to fill the compartment Treatment: sheath. 5. Perform Finkelstein’s test after injection and palpate the first compartment, to Choose from a range of options determine if the injection was effective. Since lateral epicondylitis was first described, *The clinician performing the injection should wear sterile gloves; this photo was researchers have proposed a wide variety of taken without gloves to better demonstrate hand position. treatments as initial interventions includ- ing rest, activity, equipment modification, NSAIDs, wrist bracing/elbow straps, and extensor carpi radialis brevis muscle and the physical therapy. If initial treatment does subsequent development of angiofibroblas- not produce the desired effect, second-line tic dysplasia.39 According to Regan et al who treatments include corticosteroid injections studied the histopathologic features of 11 pa- (FIGURE 8), prolotherapy (injection of an irri- tients with lateral epicondylitis, the underlying tant, often dextrose; see “Prolotherapy: Can it cause of recalcitrant lateral epicondylitis is, in help your patient?” J Fam Pract. 2015;64:763- fact, degenerative, rather than inflammatory.40 768), autologous blood injections, platelet- Although the condition has been nick- rich plasma injections (see “Is platelet-rich named “tennis elbow,” only about 5% of ten- plasma right for your patient?” J Fam Pract. nis players have the condition.41 In tennis 2016;65:319-328), and needling of the exten-

TABLE 3 Lane classification of de Quervain’s disease: A useful guide for Tx decisions34

Type 1 (mild) Type 2 (moderate) Type 3 (severe)

Finkelstein's test Minimally + Mild pain + Clearly + Pain with ADLs A few ADLs affected Mild interference with some ADLs Moderate to severe interference with nearly all ADLs Tenderness over first dorsal Minimal Moderate Moderate/severe compartment Swelling None Mild Moderate

ADLs, activities of daily living.

500 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 HAND AND ARM PAIN

FIGURE 8 3. Cheng J, Abdi S. Complications of joint, tendon, and muscle in- jections. Tech Reg Anesth Pain Manag. 2007;11:141-147. Lateral epicondylitis injection* 4. Waryasz GR, Tambone R, Borenstein TR, et al. A review of ana- tomical placement of corticosteroid injections for uncommon hand, wrist, and elbow pathologies. R I Med J. 2017;100:31-34. 5. Nepple JJ, Matava MJ. Soft tissue injections in the athlete. Sports Health. 2009;1:396-404. 6. Henton J, Jain A, Medhurst C, et al. Adult trigger finger. BMJ. 2012;345:e5743. 7. Lundin AC, Aspenberg P, Eliasson P. Trigger finger, tendinosis, and intratendinous gene expression. Scand J Med Sci Sports. 2014;24:363-368. 8. Sato ES, Gomes Dos Santos JB, Belloti JC, et al. Treatment of trig- ger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford). 2012;51:93-99. 9. Baek GH, Kim JH, Chug MS, et al. The natural history of pediatric trigger thumb. J Bone Joint Surg Am. 2008;90:980-985. 10. Gillis J, Calder K, Williams J. Review of thumb carpometacarpal arthritis classification, treatment and outcomes. Can J Plast Surg. 2011;19:134-138. 11. Yao J, Park MJ. Early treatment of degenerative arthritis of the thumb carpometacarpal joint. Hand Clin. 2008;24:251-261. 12. Ladd AL, Weiss AP, Crisco JJ, et al. The thumb carpometacarpal joint: anatomy, hormones, and biomechanics. Instr Course Lect. 2013;62:165-179. 13. Fontana L, Neel S, Claise JM, et al. Osteoarthritis of the thumb carpometacarpal joint in women and occupational risk factors: a case-control study. J Hand Surg Am. 2007;32:459-465. 14. Stamm TA, Machold KP, Smolen JS, et al. Joint protection and Determine home hand exercises improve hand function in patients with whether cervical hand osteoarthritis: a randomized controlled trial. Arthritis Rheum. 2002;47:44-49. spine disease 15. Weiss S, LaStayo P, Mills A, et al. Prospective analysis of splint- and/or ing the first carpometacarpal joint: an objective, subjective, and radiographic assessment. J Hand Ther. 2000;13:218-226. peripheral 1. Clean the area with alcohol, chorhexidine, or iodine. 16. Day CS, Gelberman R, Patel AA, et al. Basal joint osteoarthritis of neuropathy 2. Use ethyl chloride spray prior to injection to provide the thumb: a prospective trial of steroid injection and splinting. J temporary injection site pain relief. Hand Surg Am. 2004;29:247-251. are contributing 17. Gelfman R, Melton LJ 3rd, Yawn BP, et al. Long-term trends in to the patient’s 3. Ask the patient to flex the affected elbow to carpal tunnel syndrome. Neurology. 2009;72:33-41. 90 degrees. 18. Wipperman J, Potter L. Carpal tunnel syndrome-try these diag- symptoms, 4. Mark the lateral epicondyle and the radial head to nostic maneuvers. J Fam Pract. 2012;61:726-732. as patients with help with the anatomy. 19. Huisstede BM, Hoogvliet P, Randsdorp MS, et al. Carpal tunnel 5. Inject the steroid and local anesthetic mixture so syndrome. Part I: effectiveness of nonsurgical treatments—a sys- carpal tunnel that it infiltrates the tenoperiosteal junction near tematic review. Arch Phys Med Rehabil. 2010;91:981-1004. syndrome may the common extensor origin at the lateral humeral 20. Mintalucci DJ, Leinberry CF Jr. Open versus endoscopic carpal tunnel release. Orthop Clin North Am. 2012;43:431-437. have more than epicondyle. Patients usually experience immediate improvement in symptoms. 21. Soltani AM, Allan BJ, Best MJ, et al. A systematic review of the lit- one condition erature on the outcomes of treatment for recurrent and persistent *The clinician performing the injection should wear carpal tunnel syndrome. Plast Reconstr Surg. 2013;132:114-121. at play. sterile gloves; this photo was taken without gloves to 22. Atroshi I, Flondell M, Hofer M, et al. Methylprednisolone injec- better demonstrate hand position. tions for the carpal tunnel syndrome: a randomized, placebo- controlled trial. Ann Intern Med. 2013;159:309-317. 23. Raji P, Ansari NN, Naghdi S, et al. Relationship between Semmes- Weinstein Monofilaments perception test and sensory nerve sor tendon origin. Refer patients who do not conduction studies in carpal tunnel syndrome. NeuroRehabilita- improve after one corticosteroid injection to tion. 2014;35:543-552. 24. Leinberry CF, Rivlin M, Maltenfort M, et al. Treatment of car- an orthopedic surgeon for consideration of pal tunnel syndrome by members of the American Society for open or arthroscopic treatment. JFP Surgery of the Hand: a 25-year perspective. J Hand Surg Am. 2012;37:1997-2003.e3. 25. Ustün N, Tok F, Yagz AE, et al. Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: a single-blind randomized CORRESPONDENCE prospective study. Am J Phys Med Rehabil. 2013;92:999-1004. Gregory R. Waryasz, MD, Rhode Island Hospital, Department of Orthopaedic Surgery, 593 Eddy St., Providence, RI 02903; 26. Michalsen A, Bock S, Lüdtke R, et al. Effects of traditional cupping therapy in patients with carpal tunnel syndrome: a randomized [email protected]. controlled trial. J Pain. 2009;10:601-608. 27. Seok H, Kim SH. The effectiveness of extracorporeal shock wave therapy vs. local steroid injection for management of carpal tun- nel syndrome: a randomized controlled trial. Am J Phys Med Re- habil. 2013;92:327-334. References 28. Huisstede BM, Randsdorp MS, Coert JH, et al. Carpal tunnel syn- 1. Fitzgibbons PG, Weiss AP. Hand manifestations of diabetes mel- drome. Part II: effectiveness of surgical treatments—a systematic litus. J Hand Surg Am. 2008;33:771-775. review. Arch Phys Med Rehabil. 2010;91:1005-1024. 2. Peters-Veluthamaningal C, Van der Windt DA, Winters JC, et al. 29. Shehab R, Mirabelli MH. Evaluation and diagnosis of wrist pain: a Corticosteroid injection for trigger finger in adults.Cochrane Da- case-based approach. Am Fam Physician. 2013;87:568-573. tabase Syst Rev. 2009:CD005617. 30. Clarke MT, Lyall HA, Grant JW, et al. The histopathology of de

JFPONLINE.COM VOL 66, NO 8 | AUGUST 2017 | THE JOURNAL OF FAMILY PRACTICE 501 Quervain’s disease. J Hand Surg Br. 1998;23:732-734. treatment of recalcitrant de Quervain tenosynovitis with a 31. Zychowicz MA. A closer look at hand and wrist complaints. Nurse novel 4-point injection technique. Am J Sports Med. 2011;39: Pract. 2013;38:46-53. 398-403. 32. Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment 38. Scheller A, Schuh R, Hönle W, et al. Long-term results of surgi- measures for de Quervain’s disease of pregnancy and lactation. J cal release of de Quervain’s stenosing tenosynovitis. Int Orthop. Hand Surg Am. 2002;27:322-324. 2009;33:1301-1303. 33. Mani L, Gerr F. Work-related upper extremity musculoskeletal 39. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of disorders. Prim Care. 2000;27:845-864. lateral epicondylitis. J Bone Joint Surg Am. 1979;61:832-839. 34. Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain’s 40. Regan W, Wold LE, Coonrad R, et al. Microscopic histopathol- disease: role of conservative management. J Hand Surg Br. ogy of chronic refractory lateral epicondylitis. Am J Sports Med. 2001;26:258-260. 1992;20:746-749. 35. Peters-Veluthamaningal C, Van der Windt JC, Winters JC, et al. 41. Van Hofwegen C, Baker CL 3rd, Baker CL Jr. Epicondylitis in the Corticosteroid injection for de Quervain’s tenosynovitis. Co- athlete’s elbow. Clin Sports Med. 2010;29:577-597. chrane Database Syst Rev. 2009;8:CD005616. 42. Leach RE, Miller JK. Lateral and medial epicondylitis of the el- 36. Sawaizumi T, Nanno M, Ito H. De Quervain’s disease: efficacy of bow. Clin Sports Med. 1987;6:259-272. intra-sheath triamcinolone injection. Int Orthop. 2007;31:265- 43. Weerakul S, Galassi M. Randomized controlled trial local injec- 268. tion for treatment of lateral epicondylitis, 5 and 10 mg triamcino- 37. Pagonis T, Ditsios K, Toli P, et al. Improved corticosteroid lone compared. J Med Assoc Thai. 2012;95 Supp 10:S184-188.

THE JOURNAL OF FAMILY A SPECIAL SUPPLEMENT TO PRACTICE Hot Topics in Primary Care

Discussion of primary care topics includes expert insight into: • Biologics, Biosimilars, and Generics • Community-Acquired Bacterial Pneumonia • Cardiovascular Safety of Medications for Type 2 Diabetes Mellitus • Dual therapy for Type 2 Diabetes Mellitus • GLP-1R Agonists • Medication Adherence in Type 2 Diabetes Mellitus FREE -Irritable Bowel Syndrome • NSAIDs 2.0 CME CREDIT -Liver Disease • Sublingual Immunotherapy

This supplement can be found in the Education Center on the JFP website or directly at www.mdedge.com/jfponline/hottopics2017

This supplement is sponsored by Primary Care Education Consortium.

HotTopics half page ad_REV.indd 1 7/18/17 10:20 AM

502 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8